Download Gastroesophageal Reflux - Practical Management of a Common

Gastroesophageal Reflux - Practical Management of a
Common, Challenging Disorder
By: James L. Holly, MD
Most people have some acid entering the esophagus during the course of a day.
However, the amount of that acid is generally limited by a series of mechanisms:
1. The central defense is the gastroesophageal (GE) barrier, composed of the lower
esophageal sphincter (LES) and its diaphragmatic support. The ligaments of the
diaphragm and the segment of the esophagus within the abdomen contribute to
the high-pressure zone that reduces the risk of reflux.
2. The normal motion of the esophagus (esophageal peristalsis) reduces the duration
of exposure to acid by removing the bulk of refluxed gastric juice.
3. Saliva, delivered by voluntary swallowing, neutralizes the acid and restores the
pH of the fluid in the esophagus to the neutral range.
4. Normal stomach (gastric) function is also defends against gastroesophageal
reflux. Delayed gastric emptying can contribute to GERD. Most people with
reflux discover that eating large meals makes the symptoms of reflux worse,
underlining the importance of the volume of gastric contents for promoting
reflux.
Because the primary motion of the esophagus (primary peristalsis) is triggered by
voluntary swallowing, this only is present when you are awake. Although secondary
peristalsis (peristalsis in the absence of a swallowing reflex) occurs at night, the
movement of the esophagus is less frequent at night.
Factors contributing to acid in the esophagus at night include:
1. Supine posture (laying on the back)
2. Less frequent peristalsis
3. The absence of salivary neutralization of acid.
Hiatal Hernia and Gastroesophageal Reflux
Hiatal hernia was once thought to be synonymous with acid reflux. Many patients were
then found to have hiatal hernia without reflux, whither others presented with reflux
symptoms without hiatal hernia. The large majority of patients with severe esophagitis
have hiatal hernias; it is clear that a hiatal hernia is an important risk factor for severe
reflux. But, without reflux, the overwhelming majority of hiatal hernias are
asymptomatic and only a coincidental finding.
Secondary forms of Gastroesophageal Reflux (GER)
GER can be relate to the use of a variety of drugs, some of which impair motility and
others, such as non-steroidal anti-inflammatory drugs (NSAIDS), appear to directly
disrupt the lining of the esophagus itself. There is also an acid-independent form of druginduced esophagitis; certain caustic pills can cause direct contact damage to the
esophagus when they are not swallowed promptly.
There are two important forms of GER that differ in symptom patterns, pathophysiology,
natural history and therapy:
1.
2.
Mild GER (daytime, upright reflux) -- this form of gastroesophageal reflux is
associated with a benign natural history. The principle treatment will be lifestyle
measures and symptomatic therapy.
Classic, severe GER (nighttime, supine reflux) -- Reflux can occur in the
daytime or nighttime and is generally unrelenting and recurring. The damaged
caused by this form of reflux is difficult to heal and may require a class of drugs
called Proton Pump Inhibitors. Surgery may be necessary in this form of reflux.
Complications of Reflux
Complications of reflux may include pulmonary and upper airway disorders, such as
asthma, chronic cough, laryngitis, periodonitis, pharyngitis, pneumonia, pulmonary
fibrosis and bronchiectasis. GER should be considered in any unexplained inflammatory
or infectious pulmonary condition, such as asthma and recurrent infections. Key features
are nighttime or after-meal wheezing and/or cough.
Symptoms of Reflux
1.
Heartburn is the characteristic symptom of GER. This is typically a burning,
substernal discomfort or pain which rises from a point below the stomach or
lower part of the sternum (breast bone) to the top of the sternum. Symptomatic
improvement with acid inhibition provides the evidence that reflux is the cause of
the problem.
2. Acid regurgitation is another common symptom of reflux. This is marked by the
sudden, spontaneous appearance of a bitter, sour fluid in the throat or mouth.
3.
4.
Globus is a sensation of a knot in the throat related to reflux and possibly due to
spasm of the upper esophageal sphincter in response to acid in the esophagus.
Progressive or consistent difficulty in swallowing (dysphagia) is clearly an
indication for evaluation which should include endoscopy and possibly a barium
swallow.
Noncardiac Chest Pain (NCCP)
This is unexplained chest pain or discomfort that occurs in the absence of demonstrated
cardiac pathology. The question is whether this pain is the result of esophageal
dysmobility, acid reflux, irritable esophagus or undetected cardiac pathology. The
answer is probably that all these mechanisms can contribute to symptoms under different
circumstances.
The Evaluation of GER
The presentation of GER is usually sufficiently characteristic to justify a clinical
diagnosis in the large majority of cases. The confidence of the diagnosis is greatly
increased with a good response to specific antireflux therapy. If there is a change in the
pattern of the disease or if the pain is unrelieved by antacids as in the past then further
cardiac workup is recommended.
Drug treatment of GER
1.
Mild to moderate acid inhibition -- H2 antagonist are the mainstay of routine
therapy for mild GER. With the advent of generic cimetidine (Tagamet),
reduced costs drive use of this drug as appropriate first-line therapy,
particularly where intermittent use controls symptoms. Serious side effects are
uncommon and the side effects of impotence and gynecomastia are generally
only seen with higher doses.
2.
Promotility Agents such as Reglan appears to increase the lower esophageal
sphincter pressure thereby decreasing reflux.
3.
Profound Acid Inhibition: PPI -- Prilosec and Prevacid provide effective
control of acid secretion in the large majority of cases. These medications
work less well when the patient is fasting so they should be give before meals
rather than before bedtime. Dose response varies considerably among
individuals, particularly at lower dosages.
Profound acid inhibition causes elevation of serum gastrin due to removal of gastric acid
which stimulates the production of more gastrin. There are theoretical concerns about
long-term consequences of elevated gastrin such as hypertrophy of gastric mucosa,
gastric carcinoid tumors and possibly colon cancer. The clinical consequences of these
problems remain largely theoretical, but still raise some concern. There is good evidence
that Helicobacter Pylori infection accounts for a component of the elevated gastrin levels
seen with acid inhibition. Therefore, curing HP should reduce gastrin levels and lower
the theoretical risks of prolonged gastrin elevation.
Life Style Measure and Patient-controlled therapy for GER
1.
2.
3.
4.
5.
6.
7.
Avoid lying down within 3 hours of eating
Avoid food, beverages and eating habits that cause symptoms, i.e., fatty foods,
large meals, chocolate, peppermint or spearmint, alcohol, caffeine-containing
beverages or food
Stop-cigarette smoking
Suck hard candies or chew gum to increase saliva
Wear loss-fitting clothes
Lose weight
Raise head of bed 4 to 6 inches on blocks for nighttime symptoms.
Avoid drugs that reduce lower esophageal sphincter pressure and/or makes GER worse:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Progesterone (some birth control pills)
Theopylline
Tricyclic antidepressants
Narcotic Agents
Calcium Channel blockers
Serotonin Reuptake inhibitors
Sedatives
Alpha-adrenergic antagonists
Beta-adrenergic agonists
Proton Pump Inhibitors
These drugs quickly earned recognition as the most effective agents for the treatment of
GER. Success is achieved with standard dosages in at least 80% of cases with severe
GER and in a high percentage of milder cases where symptomatic control is targeted.
Superiority of PPI over other forms of therapy has been firmly established in a wide
range of well-controlled studies. Most GER patients respond to 20 mgs of Prilosec or 30
mg of Prevacid daily. About 10 t0 20% require higher dosages. Higher doses are
appropriate in instances where the patient fails to respond or a rapid initial healing
response is indicated.
Sustained Therapy
The success of PPI in initial therapy does not obviate the need of sustained therapy in
most cases of severe GER and in some of mild GER.
Surgery for GER
Two developments in the last decade have enhanced the attractiveness of surgery for
GER. First, laparoscopic techniques have proven as effective as open surgery for
fundoplication. The benefits of the laparoscopic approach are greatly decreased pain,
discomfort and recovery time following surgery. Second, surgical technique has
improved with the recognition that loose, short wraps can achieve good control of reflux
with reduced risk of postoperative complications of gas bloat and dysphagia.
Surgery is generally an appropriate option in patients with moderate to severe reflux who
are unable to tolerate or are noncompliant with medical management. Ideal surgical
candidates would be younger patients (under 50) in good general health with no
comoribidity that would complicate surgical outcomes.
This simply problem can have sustained profound health consequences. If you have
heartburn, see your healthcare provider.
Remember, it is your life and it is your health.